Basic Information
| Provider Information | |||||||||
| NPI: | 1043492499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHAEL T. GRANT, M.D., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 ORCHARD PARK RD | ||||||||
| Address2: | BUILDING B, SUITE 105 | ||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142242646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166776404 | ||||||||
| FaxNumber: | 7166776407 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 ORCHARD PARK RD | ||||||||
| Address2: | BUILDING B, SUITE 105 | ||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142242646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166776404 | ||||||||
| FaxNumber: | 7166776407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRANT | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7166776404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MICHAEL T. GRANT, M.D., P.C. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 147528 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00886879 | 05 | NY | MEDICAID |